Review of olfactory cleft roof anatomy.

Progress in skull-base endoscopic surgery has improved our knowledge of olfactory cleft (OC) anatomy. This article presents a review of current knowledge concerning the OC roof: descriptive anatomy, radiological exploration, and endoscopic observation. The OC is a narrow area in the most superior part of the nasal cavity. Its roof is the thinnest structure separating the nasal cavities from the brain; it comprises three superimposed tissues: nasal mucosa, ethmoid cribriform plate (ECP), and dura mater. The ECP comprises the anterior ECP containing the ethmoidal slit (ES) medially and the cribroethmoidal foramen (CEF) laterally; and the posterior ECP, comprising the olfactory foramina. The OC roof is bordered anteriorly by the nasal bone roof, laterally by the lateral ethmoid masses, and posteriorly by the jugum and anterior wall of the sphenoid sinuses. Imaging is crucial for analyzing this wall, providing precise detailed information on conformation and anatomic relations with adjacent structures such as the anterior ethmoidal artery. Understanding OC roof anatomy and correct interpretation of imaging are essential for safety in present-day functional endoscopic sinus surgery and anterior skull-base oncologic surgery.

THE EXPRESSION OF STEM CELL MARKERS (CD133, NESTIN, OCT4, SOX2) IN INVASIVE PITUITARY ADENOMAS.

INTRODUCTION: The pituitary gland serves as the center of the endocrine system. Stem cells are typically found in a specialized microenvironment of the tissue, called the niche, which regulates their maintenance, self-renewal, fate determination, and reaction to external influences. The aim of this study is to elucidate the role of stem cells in the initiation, invasion, and progression of pituitary adenomas. MATERIALS AND METHODS: All specimens were collected between January 2007 and April 2015. Radiological classification (invasiveness) for all cases was performed according to the Wilson-Hardy classification system. Immunohistochemical staining was performed to all specimens for CD133, Oct4, Sox2 and nestin. RESULTS: The study included 48 patients. Of 48 patients, 17 (35.4%) were male and 31 (64.6%) were female. Mean age is 47.10±14.14 (17-86 yrs.). According to the Wilson-Hardy classification system, 27 (56.3%) were non-invasive adenomas. There was no statistical significance between the expression of pituitary stem cell markers (CD133, OCT4, SOX2, nestin) and invasiveness. CONCLUSION: All stem cell markers are stained extensively in pituitary adenomas, except for SOX2 which was stained weakly. However, there is no effect of stem cells on invasiveness of pituitary adenomas because we cannot find a difference of the staining level between invasive and non-invasive adenomas. Nestin was stained extensively in functional adenomas, especially for GH, PRL, and gonadotropin secreting adenomas. SOX2 was stained extensively for ACTH-secreting adenomas.

Less invasive surgery using external fixator for the treatment of subtrochanteric femur fracture in a high-risk geriatric patient.

A 90-year-old female patient was admitted to our clinic complaining of pain in her left hip which occurred due to fall from a chair. Her medical history included memory loss and mental changes associated with Alzheimer's disease and depression. Patient's cooperation and orientation were weak. Range of motion of the left hip was restricted and painful. Radiographs of the left hip demonstrated subtrochanteric comminuted fracture of femur. Laboratory tests revealed anemia and liver insufficiency. Departments of internal medicine and anesthesiology reported high risk for surgery. Surgery was performed under spinal anesthesia on radiolucent table and in supine position. Using fluoroscopy, subtrochanteric comminuted fracture of femur was reduced. Proximally, two Schanz screws were placed through femoral neck and head in axial plane, and distally, three Schanz screws were placed through femoral shaft in coronal plane. Finally, fixation of the screws was achieved with an external fixator which was made of carbon fiber rods. Patient was allowed to sit in the bed and move around with a wheelchair as of the day of surgery. No infection or loosening of fixator occurred.

Effective Valsalva maneuvering during TCCD and unrevealed etiology of RLS.

Either transcranial color-coded Doppler (TCCD) or contrast echocardiography (CE) is the bests of clinically applicable and reproducible methods to evaluate the functionality of right-to-left shunts that can be found in different localization on atrial septum. As the anatomical features of right-to-left shunts could vary in many forms, detection of RLS by functional tests may aid the clinician to do risk prediction and management of patients. Sensitivity of TCDD or CE can be increased by performing effective Valsalva maneuvering during the test procedure. Timing of RLS during the cardiac cycles may help interpreting about the etiology of RLS, atrial septum or intrapulmonary shunts. Intrapulmonary shunts have been recently reported to be associated with RLS and frequently overlooked unless the tests prolonged up to 10th cardiac beat. Migraine, cryptogenic strokes, and paradoxic embolism are closely associated with RLS which should be evaluated by the collaboration of cardiologists and neurologists. Success of diagnostic procedure depends on high suspicion of index for RLS and application of contrast-enhanced tests that are effectively performed at each step.

Whole natal cleft excision and flap : an alternative surgical method in extensive sacrococcygeal pilonidal sinus disease.

BACKGROUND: Pilonidal sinus disease (PSD) is a benign disease caused by hair follicles in sacrococcygeal -region. Despite the use of different methods in treatment, there is no consensus reached for treatment modalities. In this study, we used a whole natal cleft excision and flap (WNCEF) method to remove the natal cleft in cases of extensive sacrococcygeal PSD. METHODS: 243 patients with PSD were evaluated retrospectively. 47 patients with extensive sacrococcygeal PSD were included in the study. In these patients, the natal cleft was excised by using a whole natal cleft excision and flap -(WNCEF) method which was performed by an incision to include all the natal cleft (Kite incision) and the remaining defect was closed with a single fasciocutaneous flap by sliding along the midline intergluteal sulcus. RESULTS: The mean age of patients was 25.7 years (17-43). The average hospital stay of patients was 2.7 days (2-4), mean operative time was 59 min (35-80), mean duration of drain removal was 2.7 days (2-4), mean postoperative follow-up was 16.4 months (3-24) and mean BMI was 26.9 (22-30). Flap edema occured in one patient (2.1%), seroma in three patients (6.3%) and surgical site infection requiring re-use of antibiotics were observed in two patients (4.2%). Flap -necrosis and failure did not occur in our patients. No recurrence was observed in any patient during an average follow-up of 16 months. CONCLUSIONS: In sacrococcygeal PSD treatment, removal of the natal cleft with Kite incision by WNCEF method and shifting of the midline completely are thought to be an effective method that can reduce recurrence.

Cardiac syncope due to pain: report of a case responsive to duloxetine treatment.

Neurocardiogenic syncope comprises situations triggered by neurological reflexes resulting in abnormal responses of the neurocardiovascular system that cause loss of consciousness. A vast number of clinical conditions may cause this disorder including pain, defecation, micturition, swallowing, cough, sudden fear or excitement, exercise, and long-time standing. Treatment options for syncope prevention are not satisfactory. Several agents were used for pharmacological treatment without success. Selective inhibitors of neuronal norepinephrine transporter (NET) like duloxetine may play a role in neurally mediated syncope by increasing synaptic norepinephrine levels. Therefore, we report the effect of duloxetine in a patient with pain-induced syncope resistant to standard regimens.

Intramedullary hydatid cyst of the cervical spine.

Hydatid disease (Echinococcosis) is a common parasitic infection caused by Echinococcus granulosus mainly in sheep-raising areas of the world. Liver, lungs and brain are the predominantly involved organs. However, 0.5-1% of the hydatid disease involves the spine and in 90% of the cases it is confined to the bone and the epidural space. Although intramedullary involvement is extremely rare, in this report, we present a 55-year-old female patient who was diagnosed with a cervical intramedullary hydatid cyst during magnetic resonance imaging of the cervical vertebrae. Accordingly, we imply that particularly in endemic areas, hydatid cyst disease should be kept in mind for the differential diagnosis of spinal mass lesions.

Longstanding skin ulcers due to Mycobacterium tuberculosis in a healthy man.

Cutaneous tuberculosis, a rare form of extrapulmonary tuberculosis, has a wide variety of clinical presentations and continues to be one of the most important dermatological diseases in developing countries.The sites of predilection are neck, supraclavicular region, axilla, and groin. Single or multiple cutaneous and subcutaneous nodules first appear and breakdown later resulting in undermined ulcers with a purulent discharge, sinuses, and disfiguring scars. We report a multifocal case of scrofuloderma in a 47-year-old immunocompetent man treated successfully with four antituberculotic drugs, albeit lately due to the loss of awareness to the disease.

Effects of the antiepileptic drugs on peripheral nerve function.

OBJECTIVE: We aimed to compare the effects of antiepileptic drugs and provide findings of peripheral nerve impairment using standard electrophysiological techniques. MATERIALS AND METHODS: Young adult outpatients with epilepsy on monotherapy for no less than 6 months with carbamazepine (CBZ), valproic acid (VPA), oxcarbazepine (OXC) and topiramate (TPM) were examined. Patients who had any other disease that could effect nerve conduction studies and who had neuropathic symptoms were excluded. RESULTS: Each group contained 15 patients and 20 healthy subjects were examined as the control group. Prolonged latency of median sensory nerve (P = 0.004), ulnar sensory nerve (P = 0.01) and sural nerve (P = 0.003) with a diminished nerve conduction velocity was observed in the CBZ group (P = 0.014, P = 0.002, P = 0.025, respectively). No correlation was found between VPA, OXC and TPM and the nerve conduction studies (P > 0.05). CONCLUSIONS: Valproic acid, oxcarbazepine and topiramate don't have effects on nerve conduction studies. Mild electrophysiological changes contribute to carbamazepine therapy.

Plasma osteoprotegerin concentrations in type 2 diabetic patients and its association with neuropathy.

BACKGROUND AND AIMS: To investigate the association of plasma osteoprotegerin (OPG) levels with diabetic neuropathy. METHODS: Forty-two diabetic patients (21 female and 21 male) and twenty-four non-diabetic healthy control subjects (12 female and 12 male) were included in the study. All consecutive diabetic patients who came for routine follow-up at our outpatient clinic were invited to participate in this clinical study. We studied EMG and neuropathy symptom score in all study subjects. Fasting plasma glucose, HbA1 C, hs-CRP, OPG levels and lipid profile were measured for each subject. RESULTS: Serum fasting glucose, HbA1c, HOMA-IR, total cholesterol, triglyserid, LDL-Cholesterol, HDL-Cholesterol, lipoprotein (a), apolipoprotein-b, hs-CRP, OPG levels, and neuropathy symptom score were statistically higher in diabetic patients than in healthy control subjects. Plasma OPG levels was statistically higher in diabetic patients than it was in nondiabetic control subjects. However, plasma OPG levels were not significantly different between diabetic patients without neuropathy and healthy control subjects. On the other hand, OPG levels were statistically higher in diabetic patients with neuropathy than in patients without neuropathy. In addition to that serum fasting glucose, HbA1c, hs-CRP, diabetes duration, neuropathy symptom score were statistically higher in diabetic patients with neuropathy than they were in patients without neuropathy. In total group of subjects, plasma OPG levels were correlated significantly with age, diabetes duration, HbA1c, total cholesterol, HDL-cholesterol, lipoprotein (a), apolipoprotein b, hs-CRP. In diabetic patients, plasma OPG correlated significantly with age, diabetes duration, neuropathy symptom score, HbA1c, lipoprotein (a), apolipoprotein b levels. CONCLUSIONS: The major findings of this study were that the plasma OPG concentrations were higher in type 2 diabetic patients than OPG concentrations in healthy control subjects and they were positively correlated with diabetic neuropathy. This finding supports the growing concept that OPG acts as an important regulator in the development of vascular dysfunction in diabetes.

Reversible myelopathy with vitamin B12 deficiency.

Vitamin B12 deficiency causes haematological, gastrointestinal, psychiatric and neurological diseases. Subacute combined degeneration (SCD) of the spinal cord, characterised by degeneration of the lateral and posterior columns, is often found due to vitamin B12 deficiency. We report SCD occurring in a 57-year-old man who presented with a 2.5-month history of gradually progressing tingling in the fingers and toes and neck ache. Laboratory data revealed vitamin B12 deficiency and magnetic resonance (MR) imaging of the cervical spinal cord demonstrated abnormal hyperintense signal changes on T2-weighted imaging of the posterior columns. In our case, follow-up MR imaging findings correlated well with clinical outcome after treatment with vitamin B12 supplements. Neurological symptoms in vitamin B12 deficiency are frequent. Early spinal MR imaging assists in the early diagnosis and treatment of the disease.

MRI findings of intracranial tuberculomas.

PURPOSE: Tuberculosis involvement of the central nervous system continues to represent a serious problem, particularly in developing countries. The aim of this study was to characterize the magnetic resonance imaging (MRI) findings of intracranial tuberculoma, a form of neurotuberculosis. METHODS: We retrospectively reviewed the data of 27 patients with intracranial tuberculomas. These consisted of 17 women and 10 men with a mean age of 26 years (14-51). MRI was performed on all patients. RESULTS: A total of 64 tuberculomas were found in these patients, of which 41 were distributed in the cerebral hemispheres, 17 in the cerebellar hemispheres, and 6 in the brainstem. Accompanied meningitis was detected in three patients, hydrocephalus in five patients, and hydrocephalus with meningitis in one patient. CONCLUSION: MRI makes a significant contribution to diagnosis of intracranial tuberculomas and can objectively determine accompanying abnormalities.

The sensitivity of clinical diagnostic methods in the diagnosis of diabetic neuropathy.

This study assessed the sensitivity of various methods for the clinical diagnosis of diabetic peripheral neuropathy. A total of 147 randomly selected patients with diabetes mellitus and 65 age- and sex-matched healthy controls were evaluated by various clinical (the neuropathy symptom score [NSS], the neuropathy disability score [NDS], vibration perception thresholds [VPTs], Tinel's sign and Phalen's sign), laboratory (fasting plasma glucose and glycosylated haemoglobin levels) and electro-physiological (nerve conduction studies, H-reflex and F-wave measurements) methods. In the patient group, 8.2% had an abnormal NSS, 28.5% had a positive Phalen's sign, 32.6% had a positive Tinel's sign, 42.8% had an abnormal VPT and 57.1% had an abnormal NDS. Significant correlations were found between electro-physiologically confirmed neuropathy and the two provocation tests and abnormal VPTs. In conclusion, assessment with a complete neurological examination and standard electrophysiological tests is very important for the diagnosis of diabetic peripheral neuropathy and the prevention of morbidity in patients with or without symptoms.

Potential effects of zinc on information processing in boys with attention deficit hyperactivity disorder.

PURPOSE: The aims of the present study were to investigate the relationship between plasma zinc levels and amplitudes and latencies of P1, N2, and P3 in parietal and frontal areas in children with ADHD, and to compare these zinc levels and event-related potentials (ERPs) indices with controls. METHODS: 28 boys with ADHD were divided into two groups according to plasma zinc levels: low zinc group (N=13, zinc level <80 microg/dL) and zinc non-deficient group (N=15, zinc level >or=80 microg/dL). ERP indices from parietal and frontal brain regions were recorded in children with ADHD and in 24 normal boys by using an auditory oddball paradigm. Plasma zinc levels were measured by an atomic absorption spectrophotometer. RESULTS: The plasma zinc levels were significantly lower in both ADHD groups (means are 65.8 microg/dL in low zinc group and 89.5 microg/dL in zinc non-deficient group) than controls (mean: 107.8 microg/dL; both p values <0.017). In ADHD compared to controls, the amplitudes of P3 in frontal and parietal regions were significantly lower, and the latency of P3 in parietal region was significantly longer (all p values <0.017). In low zinc ADHD group compared to zinc non-deficient ADHD group, the latencies of N2 in frontal and parietal region were significantly shorter (all p values <0.017). In addition, there was a medium but significant positive correlation between plasma zinc levels and amplitude and latency of frontal N2 wave in ADHD. CONCLUSIONS: These results can suggest that plasma zinc levels might have an effect on information processing in ADHD children, and lower zinc levels seem to affect N2 wave. Since N2 wave changes may reflect a different inhibition process, further studies are warranted to investigate the effect of zinc on inhibitory process in children with ADHD, and in low zinc and non-deficient ADHD groups.

Relationship between tuberculous otomastoiditis and tuberculous meningitis.

OBJECTIVE: The aim of this study was to determine the correlation between tuberculous meningitis and tuberculous otomastoiditis. MATERIALS AND METHODS: Meningeal involvement sites were investigated by magnetic resonance imaging in 32 patients (21 males, 11 females) who had previously been diagnosed with tuberculous meningitis. Clinical and laboratory findings and responses to anti-tuberculous treatment were evaluated, and the presence of concomitant tuberculous otomastoiditis was also investigated. RESULTS: The meningeal involvement site was unilateral (in the sylvian fissure and the perimesencephalic cistern) in 28 patients (87.5 per cent), and bilateral and widespread in four patients (12.5 per cent). Tuberculous otomastoiditis was found in 11 of the patients with tuberculous meningitis (34.3 per cent). Otomastoiditis was on the same side as the meningeal involvement in nine of these 11 patients. Bilateral otomastoiditis with meningeal involvement was observed in two patients. CONCLUSIONS: Tuberculous meningitis is frequently accompanied by otomastoiditis, although the exact causal relationship between the two conditions is unclear. Since meningitis is a serious clinical condition, concomitant otomastoiditis generally remains unrecognised. Tuberculosis should be considered in the differential diagnosis of patients with otitis or otomastoiditis who do not respond to antibiotic therapy.